Grievances and Appeals
A grievance is any complaint or dispute, expressing dissatisfaction with any aspect of the operations, activities, or behavior of our organization, regardless of whether you request remedial action be taken. A grievance may also include a complaint regarding a refusal to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.
Grievances do not involve problems related to approving or paying for Part D drugs or a Low Income Subsidy (LIS) or Late Enrollment Penalty (LEP) determination (See Appeal).
You would file a grievance if you have a complaint regarding us or one of our network pharmacies. For example, you would file a grievance if you have a complaint about things such as wait times when filling a prescription, rude behavior by a network pharmacist or other staff, problems with the customer service you receive, and difficulty getting or understanding information you need or request.
If you have a grievance, we encourage you to call our Customer Service department immediately. We will make every attempt to resolve your complaint over the phone. If you ask for a written response, file a written grievance, or your complaint is related to your quality of care, we will respond in writing to you as quickly as your case requires based on your health status, but no later than thirty (30) calendar days after we receive your grievance. You are not required to submit your grievance in writing. You may file your grievance by phone, by mail or in person.
When a delay would significantly increase any risk to your health, you have the right to ask for a "fast" or "expedited" grievance. This means we will respond to your grievance within twenty-four (24) hours of receipt of your request. If we cannot respond to your grievance within that twenty-four (24) hour time frame because necessary information is needed, we will notify you verbally and in writing (before the 24 hours) of the reason for the delay. All notifications involving the decision will include information about the basis of our decision and describe any additional rights you may have. All grievances involving clinical decisions will be made by qualified clinical personnel.
Your grievance must be submitted within sixty (60) calendar days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than thirty (30) calendar days after receiving your complaint. We may extend the time frame by up to fourteen (14) days if you ask for the extension, or if we can justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.
Complaints concerning the quality of care received under Medicare may be made in oral or written format to us under the grievance process, or to an independent organization called the Quality Improvement Organization (QIO), or to both. For example, if you believe your pharmacist provided the incorrect dose of a prescription, you may file a complaint with the QIO in addition to or in lieu of a complaint filed under our grievance process. For any complaint filed with the QIO, we must cooperate with the QIO to resolve the complaint.
By Phone:
Call Customer Care toll-free at 1-800-514-6930 (TTY/TDD 1-800-662-1220) 8 a.m. to 8 p.m., Monday – Friday. From Oct. 1 to Mar. 31, representatives will be available seven days a week from 8 a.m. to 8 p.m.
By Fax:
Send to 315-671-6656.
By Mail:
Simply Prescriptions
Advocacy Department
PO Box 4717
Syracuse, NY 13221
By Email:
Submit a Grievance via Secure Eform
In Person:
Please call Customer Service for information on filing your grievance in person.
Initial Determinations
The initial determination we make is the starting point for dealing with requests you may have about covering a Part D drug or paying for a Part D drug you already received. Initial decisions about Part D drugs are called "coverage determinations". With this decision, we explain whether we will provide the Part D drug you are requesting, or pay for the Part D drug you already received.
What is an exception?
An exception is a type of initial determination (also called "coverage determination") involving a Part D drug. You may ask us to make an exception to our Part D coverage rules in a number of situations. For example, you would file an exception if you want to ask us to cover your Part D drug even if it is not on our formulary, to waive coverage restrictions or quantity limits on your Part D drug, or to provide a higher level of coverage for your Part D drug.
Asking for a "standard" or "fast" Initial Determination
You may submit a request outside of regular business hours and on weekends at: 1-877-444-5380.
A decision about whether we will give you, or pay for, the Part D drug you are requesting may be a "standard" decision that is made within the standard time frame, or it may be a "fast" (also called "expedited") decision that is made more quickly.
Standard Initial Determination
To request a standard decision for a Part D drug (including a request to pay you back for a Part D drug that you have already received), you, your doctor or other prescriber, or your representative may call, fax, or write us using the contact information above.
Generally, we must give you our decision no later than seventy-two (72) hours after we receive your request, but we will make it sooner if your request is for a Part D drug that you have not received yet and your health condition requires us to. However, if your request involves a request for an exception, we must give you our decision no later than seventy-two (72) hours after we receive a statement from your physician explaining why the drug you are asking for is medically necessary.
Fast (or "Expedited") Initial Determination
You may ask for a fast decision only if you, your doctor or other prescriber believe that waiting for a standard decision could seriously harm your health or your ability to function and the request is for a Part D drug that you have not received yet. You may ask us to give you a fast decision by calling, faxing, or writing us using the contact information above.
We will give you our decision within twenty-four (24) hours after you or your doctor, ask for a fast review.
If your request involves a request for an exception, we must give you our decision no later than twenty-four (24) hours after we receive a statement from your physician explaining why the drug you are asking for is medically necessary.
What happens if we deny your Coverage Determination Request?
If we deny your request for coverage of or payment for a Part D prescription drug, we will send you a written notice explaining why we denied your request and provide you with your appeal rights (See Appeal Level 1).
Any of the procedures that deal with the review of adverse coverage determinations made by us on the benefits under your Part D plan that you believe you are entitled to receive. These procedures include redeterminations by us, reconsiderations by the independent review entity (IRE), Administrative Law Judge (ALJ) hearings, reviews by the Medicare Appeals Council (MAC), and judicial reviews.
Appeal Level 1:
If you do not agree with our decision to deny your coverage determination in whole or in part, you may ask us to review our denial decision. This request is called a "redetermination". You must file your appeal request within sixty (60) calendar days from the date on the written notice of denial of your coverage determination. We may give you more time if you have a good reason for missing the deadline.
When we receive your request for a redetermination, it is reviewed by professionals within our organization who were not involved in making the original coverage determination decision. This process ensures that we give your request a thorough review, independent of the original review.
You have the right to request a standard appeal or a fast appeal of a redetermination. A fast appeal is also called an "expedited" appeal.
To request a standard or expedited coverage redetermination for a Part D drug, you, your doctor or other prescriber, or your representative may call, fax or write to us.
Standard Appeal
Once we receive your request for an appeal, we have seven (7) calendar days (for a standard request for coverage or for a request to pay you back) from receipt of your request to make our decision. We will give you the decision sooner if you have not received the drug yet and your health condition requires us to.
Expedited Appeal
If your doctor or other prescriber indicates that waiting seven (7) calendar days could seriously harm your life or health or your ability to regain maximum function, we will give you a decision within seventy-two (72) hours.
For a Standard Appeal (Level 1)
For members/providers: Medicare Prescription Drug Redetermination Request FormOpens a PDF
Mail your request to:
Simply Prescriptions
Advocacy Department
PO Box 4717
Syracuse, NY 13221
Send it to us by fax: 1-315-671-6656
Send it to us by Email: Submit an Appeal via Secure Eform
For an Expedited Appeal (Level 1), mail your appeal to the address above, or call Customer Care toll-free at 1-800-805-9366 (TTY/TDD 1-800-662-1220) 8 a.m. to 8 p.m., Monday – Friday From Oct. 1 to Mar. 31, representatives will be available seven days a week from 8 a.m. to 8 p.m.
Outside of regular hours and on weekends: 1-877-444-5380
Appeal Level 2: Review by an Independent Review Entity (IRE)
If we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the IRE that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. This review is called a "reconsideration." You must send the appeal request in writing to the IRE. The decision you receive from us (Appeal Level 1) will tell you how to file this appeal, including who may file the appeal and how soon it must be filed. You have the right to request a standard appeal (seven (7) calendar day response) or an expedited appeal (seventy-two (72) hour response).
Appeal Level 3: Hearing with an Administrative Law Judge (ALJ)
If the IRE does not rule completely in your favor, you may ask for a review by an Administrative Law Judge (ALJ). Your written request must be filed with an ALJ within sixty (60) calendar days of the date you were notified of the decision made by the IRE (Appeal Level 2). To receive an ALJ hearing, the dollar value of the Part D drug you asked for must meet the minimum requirement. The decision you receive from the IRE will tell you if you meet the requirement, how to file this appeal and explain who may file it.
Appeal Level 4: Review by the Medicare Appeals Council (MAC)
If the ALJ does not rule completely in your favor, you may ask for a review by the Medicare Appeals Council (MAC). You must make the request in writing within sixty (60) calendar days of the date you were notified of the decision made by the ALJ (Appeal Level 3). The decision you receive from the ALJ will tell you how to file this appeal, including who may file it.
Appeal Level 5: Review by a Federal Court
If the MAC does not rule completely in your favor or the MAC decided not to review your appeal request, you have the right to continue your appeal by asking a Federal Court Judge to review your case. To receive a review by a Federal Court Judge, the amount involved must meet the minimum requirement specified in the MAC's decision. You must make the request in writing within sixty (60) calendar days from the date of the notice of the MAC's decision. The letter you get from the MAC will tell you how to request this review, including who may file the appeal.
Who May File a Grievance or Appeal
You, your physician/other prescriber or someone you name may file a grievance, initial determination or appeal. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. The representative statement must include your name and Medicare number. You may use Form CMS-1696Opens a PDF. You may also use an equivalent notice which satisfies the requirements in Form CMS-1696.
You have the right to have a lawyer act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will provide you free legal services if you qualify. You may want to call the Medicare Rights Center at 1-888-HMO-9050 or the Medicare Elder Care locator at 1-800-677-1116. Unless otherwise stated, your appointed representative will have all of your rights and responsibilities during the grievance or appeals process.
Where to Learn More
You may request the aggregate number of our grievances, appeals, and exceptions by contacting the Customer Service department.
Simply Prescriptions contracts with the Federal Government and is a PDP plan with a Medicare contract. Enrollment in Simply Prescriptions depends on contract renewal. Submit feedback about your Medicare prescription drug plan at www.Medicare.gov or by contacting the Medicare Ombudsman. _.
This page last updated 10-01-2023.
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